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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604315
Report Date: 10/04/2022
Date Signed: 10/04/2022 05:28:20 PM


Document Has Been Signed on 10/04/2022 05:28 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



FACILITY NAME:CARING HEARTS COTTAGEFACILITY NUMBER:
374604315
ADMINISTRATOR:LAZARUS, AARONFACILITY TYPE:
740
ADDRESS:682 VALE VIEW DRTELEPHONE:
(619) 246-0731
CITY:VISTASTATE: CAZIP CODE:
92081
CAPACITY:6CENSUS: 5DATE:
10/04/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:59 PM
MET WITH:Administrator, Aarn LazarusTIME COMPLETED:
05:35 PM
NARRATIVE
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Licensing Program Analyst (LPA) Janira Arreola, conducted an unannounced annual while at the facility for a separate visit. LPA met with Aaron Lazarus, Administrator, who was informed of the purpose of the visit. LPA observed (2) staff members and (5) residents at the time of the visit.

LPA conducted a walk-through the the interior and exterior of the facility. LPA observed the facility to have (5) bedrooms and (3) bathrooms. The facility has a laundry room, basement, and outdoor area. LPA observed the resident rooms where residents would be isolating in case of COVID-19. LPA observed the facility to have adequate hand hygiene supplies, and 30-day supply of PPE equipment. Administrator informed LPA on staff leave, staff procedures when testing positive for COVID-19, and staffing plan in case of shortages. LPA observed one central entry point where symptoms screening and sign in sheet are being kept. LPA observed COVID-19 posting throughout the facility. The staff are trained on how to properly use PPE and have been N95 FIT tested.

LPA reviewed the facility roster and found that all staff have been associated and fingerprint cleared. LPA observed the facilities paper supplies, and food supply while at the facility. LPA observed where the facility is keeping the sharp objects and medications locked in a hallway cabinet by the kitchen. LPA observed seating areas both indoors and outdoors.

LPA observed a locked gate on facility kitchen access point. LPA asked Administrator if the facility had a waiver or exception for this gate, who stated there was none. Administrator stated he was not aware a waiver or exception was needed for a gate. LPA will cite deficiency and document plan of correction for this gate.

An exit interview was conducted where this report, LIC809-D, and appeal rights were reviewed with Administrator Aaron Lazarus.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:
DATE: 10/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/04/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/04/2022 05:28 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507


FACILITY NAME: CARING HEARTS COTTAGE
FACILITY NUMBER: 374604315

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/04/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Request Denied
Type B
Section Cited
CCR
87468.1(a)
87468.1 Personal Rights of Residents in All Facilities
(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:
(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above with a locked gate leading to the kitchen of the facility. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/24/2022
Plan of Correction
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Licensee will apply for the appropriate exception or waiver to have an authorized locked kitchen gate. LIcensee shall submit there materials by the POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:
DATE: 10/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/04/2022
LIC809 (FAS) - (06/04)
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